=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003780701
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIQUELLA ALEENE YOUNG ND, LAC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2025
-----------------------------------------------------
Last Update Date | 10/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7886 SE 13TH AVE
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97202-6300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-956-9396
-----------------------------------------------------
Fax | 503-206-4791
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 920 SE TACOMA ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97202-6528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-732-7983
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 175F00000X
-----------------------------------------------------
Taxonomy Name | Naturopath
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------